**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, video review, and interviews the facility failed to supervise cognitively impaired residents who were high risk for elopement. Resident #1 exited the facility and Residents #5 and #6 remained at high risk for elopement, 3 (#1, #5, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) on 04/07/2024 at 2:50 a.m. when Resident #1, a moderately cognitively impaired resident who ambulated with a walker, was unsupervised and eloped from the facility. Resident #1 crawled out of the window in her room and exited the facility. Staff did not realize Resident #1 eloped from the facility until staff received a phone call from the S9 Responsible, reporting the Resident #1 was found at a gas station approximately one mile from the facility. Resident #1 walked down a dark single lane highway and a 4 lane divided highway during the night. Resident #1 was returned to the facility on [DATE] at approximately 3:30 a.m. by S9 Responsible Party. The IJ continued as a review of facility video surveillance from 09/19/2024 from 11:18 p.m. until 5:18 a.m. revealed staff were not performing visual checks on remaining residents (Resident #5 and Resident #6) who resided on Hall A and were identified at risk for elopement. The facility's system to adequately supervise residents every two hours according to the facility's routine resident checks policy is deficient. S3 Assistant Administrator and S2 Corporate Nurse were notified of the Immediate Jeopardy on 09/24/2024 at 5:20 p.m. This deficient practice had the likelihood to cause more than minimal harm to the remaining ten residents at risk for elopement residing in the facility. The Immediate Jeopardy was removed on 09/25/2024 at 10:18 a.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Review of facility's Wandering and Elopements Policy and Procedure (revised November 15, 2023) revealed in part: Policy: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Identifying residents at risk: 2. if identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Wandering and elopement protocols: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or Director of Nursing (DON). 2.Instruct another staff member to inform charge nurse or DON that a resident has left the premises. 3. When the resident returns to the facility, the DON or charge nurse shall: examine the resident for injuries, notify the attending physician and report findings .complete and file report of incident/accident, document the event in the resident's medical record and notify regulatory agencies per state guidelines as indicated. Review of facility's Routine Resident Checks Policy Statement (no date) revealed in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each resident at least four times per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. Review of the Resident #1's medical record revealed an admission date of 02/27/2024 with diagnoses including but not limited to: chronic obstructive pulmonary disease/unspecified, heart failure/unspecified, chronic kidney disease/unspecified, depression/unspecified, insomnia/unspecified, problems related to living alone, at risk for elopement and history of falling. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #1 had a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #1's Elopement assessment dated [DATE] revealed an elopement score of 3.0 indicating resident is at risk. (Score > = 1 = At Risk for Elopement). Review of an internet mapping site revealed Resident #1 was located approximately 1 mile from the facility and had to walk down a single lane highway and a 4 lane divided highway at night. Review of Resident #1's Physician's orders revealed an order dated 04/04/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, and elopement every 2 hours for elopement risk. Review of Resident #1's progress notes revealed an entry on 04/04/2024 at 5:53 p.m. read in part, Resident #1 sitting near front door crying with bags packed. When asked what was wrong, resident stated she wants to go home, she is not going back to her room . Will notify all staff to monitor res closely. Further review revealed a late entry on 04/07/2024 at 3:18 a.m. read in part, at approximately 2:50 a.m. staff nurse received a phone call from Resident #1's S9 Responsible Party, stating Resident #1 was found at a gas station. Staff on shift had previously observed resident or what appeared to be the resident asleep in the bed. Upon further inspection, it was noted by staff that the bed was stuffed with pillows and blankets to resemble a body asleep in bed. Upon searching by staff, resident was not found anywhere in the building. The window in Resident #1's room was observed by staff to be raised open, which leads to the outside of the building area. At approximately 3:30 a.m. resident was returned to the facility via S9 Responsible Party . Will continue to monitor and maintain safety measures while on shift. During a telephone interview on 09/19/2024 at 3:50 p.m. S9 Responsible Party of Resident #1, reported resident has dementia and was transferred to a memory care unit. S9 Responsible Party further reported she thought staff were supposed to be doing checks every 2 hours on the residents. S9 Responsible Party confirmed on 04/07/2024 at approximately 3:00 a.m. a gas station clerk notified her Resident #1 was wandering in the parking lot. S9 Responsible Party reported on 04/07/2024 she picked up Resident #1 from the gas station and returned her to the facility at approximately 3:30 a.m. S9 Responsible Party further reported on the way back to the facility she contacted the facility and requested staff check on Resident #1. S9 Responsible Party reported staff confirmed Resident #1 was not in her room. During an interview on 09/23/2024 at 10:10 a.m. S5 Receptionist reported she had witnessed Resident #1 following visitors and/staff out of the locked double doors to the front entrance of the facility prior to 04/07/2024. S5 Receptionist further reported she witnessed Resident #1 during the week of 04/01/2024 walking out behind someone and noticed her walking down the street not realizing she was a resident. S5 Receptionist reported staff was notified and Resident #1 was brought back to the facility. During a telephone interview on 09/23/2024 at 11:45 a.m. S8 Licensed Practical Nurse (LPN) confirmed she worked on 04/07/2024 when Resident #1 eloped. S8 LPN confirmed the night of 04/07/2024 Resident #1's S9 Responsible Party called and told staff she was on her way to pick up Resident #1 at the gas station. S8 LPN reported Resident #1 left out the window in her room. During an interview on 09/23/2024 at 12:15 p.m. S10 Business Office reported Resident #1 would see her put her purse on and follow her to the front door, wanting to leave. During a telephone interview on 09/23/2024 at 11:38 a.m. S6 Former Assistant Director of Nursing (ADON) reported Resident #1 had behaviors of wanting to leave the facility. During an interview on 09/23/2024 at 1:20 p.m. S4 DON reported Resident #1 always had her bag packed and had exhibited exit seeking behaviors. During an interview on 09/23/2024 at 2:20 p.m. S2 Corporate Nurse reported Resident #1 had been exhibiting exit seeking behaviors. S2 Corporate Nurse further reported Resident #1 would carry her bags around wanting to go home. During a review on 09/24/2024 at 11:55 a.m. of the facility's video surveillance of Hall A dated 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift with S2 Corporate Nurse and S3 Assistant Administrator revealed staff failed to perform visual checks every 2 hours on residents. Resident #5 and Resident #6 resided on Hall A and were identified at risk for elopement. Review of Resident #5's medical records revealed an admit date of 11/22/2022 with diagnoses including but not limited to: cognitive communication deficit, dementia in other diseases classified elsewhere/moderate with anxiety, insomnia/unspecified, schizoaffective disorder/bipolar type, and major depressive disorder/recurrent/moderate. Review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 1 (severely cognitively impaired). Review of Resident #5's Elopement Risk Evaluation dated 09/23/2024 revealed a score of 1.0 (Score > = 1 = At Risk for Elopement) indicating at risk for elopement. Review of Resident #5's Physician's orders revealed an order dated 08/23/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, elopement every 2 hours. Review of Resident #6's medical records revealed an admit date of 08/22/2024 with diagnoses including but not limited to: unspecified dementia/unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #6's MDS assessment dated [DATE] revealed a BIMS score of 00 (severely cognitively impaired). Review of Resident #6's Elopement Risk Evaluation dated 09/23/2024 revealed a score of 1.0 (Score > = 1 = At Risk for Elopement) indicating at risk for elopement. Review of Resident #6's Physician's orders revealed an order dated 08/23/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, elopement every 2 hours. During an interview on 09/24/2024 at 12:25 p.m. S2 Corporate Nurse acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S2 Corporate Nurse further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents, including Resident #5 and Resident #6 identified at risk for elopement, every 2 hours according to facility policy. S2 Corporate Nurse acknowledged the lack of supervision had the potential to adversely affect the remaining ten residents identified at risk for elopement. During an interview on 09/24/2024 at 12:25 p.m. S3 Assistant Administrator acknowledged video surveillance of Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S3 Assistant Administrator further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents. Observation on 09/24/2024 at 9:20 a.m. revealed Resident #5 walking around nursing station and staff were redirecting her. Observation on 09/24/2024 at 9:20 a.m. revealed Resident #6 self-propelling her wheelchair down the hallway. Observation on 09/25/2024 at 9:45 a.m. revealed Resident #5 pushing her wheelchair in the hallway being redirected by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video review, an interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently by failing to have an adequate system in place to ensure 3 (#1, #5, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents who were at risk for elopement were adequately supervised to prevent elopement from the facility. The lack of administrative oversight resulted in an Immediate Jeopardy on 04/07/2024 at 2:50 a.m. when Resident #1, a moderately cognitively impaired resident who ambulated with a walker, was unsupervised and eloped from the facility. Resident #1 crawled out of the window in her room and exited the facility. Staff did not realize Resident #1 eloped from the facility until staff received a phone call from S9 Responsible Party, reporting the Resident #1 was found at a gas station. Resident #1 was located at a gas station approximately one mile from the facility, Resident #1 walked down a dark single lane highway and a 4 lane divided highway during the night. Resident #1 was returned to the facility on [DATE] at approximately 3:30 a.m. by S9 Responsible Party. Resident #1 was assessed on 04/04/2024 as at risk for elopement and protective measures had not been put into place related to Resident #1's recent documented history of exit seeking behaviors. Review of facility video surveillance from 09/19/2024 from 11:18 p.m. until 5:18 a.m. revealed staff were not performing visual checks on remaining residents (Resident #5 and Resident #6) who resided on Hall A and were identified at risk for elopement. The facility's system to adequately supervise residents every two hours according to the facility's routine resident checks policy is deficient. S3 Assistant Administrator and S2 Corporate Nurse were notified of the Immediate Jeopardy on 09/24/2024 at 5:20 p.m. This deficient practice had the likelihood to cause more than minimal harm to the remaining ten residents at risk for elopement residing in the facility. The Immediate Jeopardy was removed on 09/25/2024 at 10:18 a.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Cross Reference F689 Review of facility's Wandering and Elopements Policy and Procedure (revised November 15, 2023) revealed in part: Policy: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. Review of facility's Routine Resident Checks Policy Statement (09/23/2024) revealed in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each resident at least four times per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. During a review on 09/24/2024 at 11:55 a.m. of the facility's video surveillance on the Hall A dated 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift with S2 Corporate Nurse and S3 Assistant Administrator revealed staff failed to perform visual checks every 2 hours on residents. Resident #5 and Resident #6 resided on Hall A and were identified at risk for elopement. During an interview on 09/24/2024 at 12:25 p.m. S2 Corporate Nurse acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S2 Corporate Nurse further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents every 2 hours according to facility policy. S2 Corporate Nurse acknowledged the lack of supervision had the potential to adversely affect the remaining ten residents identified at risk for elopement. S2 Corporate Nurse acknowledged the facility failed to ensure nurses were performing visual checks and CNAs were rounding every two hours. S2 Corporate Nurse reported administration should be monitoring the night shifts to ensure monitoring every two hours is being completed. During an interview on 09/24/2024 at 12:25 p.m. S3 Assistant Administrator acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S3 Assistant Administrator further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and observations the facility failed to provide adequate supervision for 2 (#1, #2) of 4 (#1, #2, #3, #4) sampled residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement. The deficient practice resulted in Immediate Jeopardy for Resident #1 and Resident #2 on 09/05/2023 at 1:54 p.m. when Resident #1 pushed Resident #2 in her wheelchair and exited through the Hall A door of the facility. At 2:33 p.m. on 09/05/2023, Resident #1 and Resident #2 were seen in the median of a four lane public road and observed crossing over the last two lanes into a grocery store parking lot by S3 Physical Therapist. Physical Therapist called and notified facility of residents being out of the building and at 2:35 p.m. on 09/05/2023 staff members, including S1 Administrator, exited the facility. On 09/05/2023 at 2:46 p.m. Resident #1 and Resident #2 returned to facility assisted by S4 Medical Records and S5 RN (Registered Nurse). Resident #1 and Resident #2 were assessed with no injuries noted and placed on every 2 hour monitoring. The Immediate Jeopardy continued for 2 other (#3, #4) residents at risk for elopement until 09/05/2023 at 2:46 p.m. when S6 Unit Manager closed the Hall A exit door. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's Wandering and Elopements Policy with revision date of March 2019 revealed in part: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Resident #1 Review of Resident #1's medical record revealed an admit date of 08/19/2022 and diagnoses including but not limited to: Alzheimer's disease and bipolar disorder with psych features. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 06/22/2023 revealed in part, Resident #1 had a BIMS (Brief Interview Mental Status) score of 5 indicating severe cognitive impairment, wandering behavior occurred 0 days during 7 day look back period, and Resident #1 received antipsychotic medication for 4 of the 7 day look back period. Review of Resident #1's physician orders prior to incident on 09/05/2023 revealed in part: Zoloft 100mg (milligrams) 1 by mouth every day. Seroquel XR 400mg 1 by mouth every day at 5 pm Monitor resident for behaviors every shift for use of psychotropics. Monitor resident for side effects of antipsychotic medication every shift. Review of Resident #1's Comprehensive Care Plan 08/05/2023 revealed Resident #1 was care planned for risk of elopement with interventions including place resident's picture at exits to identify not to let resident out, note which exits resident favors for elopement and alert staff working near those areas. Further review of Resident #1's care plan did not reveal an intervention for monitoring resident's whereabouts. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 was found to be at risk for elopement. Review of Resident #1's September 2023 progress notes revealed in part: 09/06/2023 late entry for 09/05/2023 by S7 RN- [NAME] clerk notified S5 RN of someone had called facility and stated 2 residents were outside facility grounds. S5 RN then told writer Residents were last seen between 1:30-1:40 p.m. by writer. Noted Hall A outside door was propped open by plumber working in building on Hall A. Hall A door closed and plumber notified to keep door closed at all times for safety. No apparent injuries to resident when arrived back to facility. Family notified by S6 Unit Manager. 09/08/2023 at 11:11 a.m. late entry for 9/5/2023 by S6 Unit Manager. Resident #1 head to toe assessment completed when back inside facility from elopement incident - skin intact, Resident #1 alert. No distress noted. Blood pressure 128/76, pulse 70, Respirations 18, Temperature. 98.2. Resident #1's whereabouts to be monitored every 2 hours. Resident #2 Review of Resident #2's medical record revealed a readmit date of 07/24/2013 and diagnoses including but not limited to: Hemiplegia following CVA (cerebral vascular accident) affecting right dominant side, dementia, and anxiety. Review of Resident #2's Quarterly MDS dated [DATE] revealed in part, Resident #2 had a BIMS score of 7 indicating severe cognitive impairment, wandering behavior occurred 0 days during 7 day look back period, and Resident #1 received antianxiety medication for 7 of the 7 day look back period. Review of Resident #2's physician orders prior to incident on 09/05/2023 revealed in part: Lorazepam 0.5mg 1 by mouth every 12 hours Monitor for behaviors every shift for use of psychotropic medication. Monitor for medication side effects every shift. Review of Resident #2's Comprehensive Care Plan 08/07/2023 revealed Resident #2 was not care planned for risk of elopement until after elopement incident on 09/05/2023. Review of Resident #2's Elopement Risk assessment dated [DATE] revealed Resident #2 was found not to be at risk for elopement. Review of Resident #2's September 2023 progress notes revealed in part: 09/08/2023 at 11:24 p.m. late entry for 09/05/2023 by S6 Unit Manager- Resident #2 was pushed in wheelchair by another resident (Resident #1) outside and off facility grounds. Resident #2 was brought back to facility by nurse. Head to toe assessment done, no skin breakdown or bruising noted. Resident #2 at normal self. NP (Nurse Practitioner) and family notified. 09/08/2023 at 1:02 p.m. by S6 Unit Manager- Follow up from incident on 09/05/2023, Resident #2 up in dining room, no complaint of pain or distress at this time. Blood pressure 128/76, Pulse 79, Respirations 18, Temperature 98.2. During an observation on 09/19/2023 at 3:30 p.m. of facility surveillance video from 09/05/2023 at 1:54 p.m. revealed Resident #1 pushing Resident #2 in wheelchair on Hall A when Resident #1 reached fire doors at end of Hall A, Resident #1 pushed door open and Resident #1 walked through doors pushing Resident #2 in her wheelchair. Resident #1 and Resident #2 were not seen again on video until 2:46 p.m. when Resident #1 and Resident #2 were brought back to the facility by facility staff members. During an interview on 09/19/2023 at 3:30 p.m. S1 Administrator confirmed Resident #1 and Resident #2 were found off facility property in a local grocery store parking lot on 09/05/2023 after being notified by S3 Physical Therapist residents were out of the facility, and residents should not have been out of facility unsupervised. During an interview on 09/19/2023 at 4:10 p.m. S1 Administrator confirmed Hall A door had been propped open and no facility door should be propped open. During an interview on 09/18/2023 at 2:40 p.m.S3 Physical Therapist reported on 09/05/2023 she was taking a late lunch and had left the facility to go pick up her food when she saw Resident #1 and Resident #2 in the median that separates a public 4 lane road. S3 Physical Therapist reported she got into a turn lane so she could follow the residents and at same time called the facility to notify them of the two residents being out of the facility. S3 Physical Therapist reported she was able to observe the two residents as they crossed over the last 2 lanes of the public 4 lane road into a local grocery store parking lot. S3 Physical Therapist further reported facility staff arrived at the local grocery store parking lot and were able to get residents into a vehicle and take residents back to the facility. S3 Physical Therapist reported she could no longer remember the exact time this incident happened, but stated it was around 2:30 p.m. to 2:45 p.m. During an observation on 09/18/2023 at 4:50 p.m. surveyor observed the local grocery store parking lot in which Resident #1 and Resident #2 were found on 09/05/2023. Surveyor was also able to observe the public 2 lane service road and the public 4 lane road in which residents had to cross to get to the local grocery store parking lot. Surveyor was able to determine the local grocery store parking lot was two tenths of a mile from the facility. During an interview on 09/19/2023 at 1:15 p.m. S5 RN reported on 09/05/2023 she was told by a ward clerk that a phone call had been received informing facility of two residents being out in a local grocery store parking lot. S5 RN reported she got in her car and drove over to the local grocery store parking lot and was able to get Resident #1 and Resident #2 into the car and back to the facility. S5 RN further reported she was not sure of the exact time the incident happened but thought it was sometime around 2:30 p.m. - 2:45 p.m. During an interview on 09/19/2023 at 1:20 p.m. S4 Medical Records reported on 09/05/2023 the ward clerk told her she had received a call reporting two residents were in a local grocery store parking lot. S4 Medical Records reported she rode with S5 RN to the local grocery store parking lot and assisted with bringing residents back to the facility. S4 Medical Records reported she was unsure of the incident time but believed it was around 2:30 p.m. Attempted to contact S9 [NAME] Clerk via telephone on 09/19/2023 at 3:20 p.m. S9 [NAME] Clerk did not answer the phone and by end of survey had not returned phone call. Attempted to contact S10 CNA via telephone on 09/20/2023 at 8:05 a.m. and again on 09/20/2023 at 12:30 p.m. without success. During an interview on 09/19/2023 at 11:00 a.m. S7 RN reported on 09/05/2023, the day of the elopement incident, she was working on Hall A, Hall B, and part of Hall C. S7 RN reported she had seen S8 Housekeeping and another man working down near the last rooms of the Hall A on 09/05/2023. S7 RN reported Resident #1 and Resident #2 were sitting in common area across from Nurse Station II and the last time she saw the residents prior to the elopement incident was at about 1:40 p.m. S7 RN reported after hearing two residents were out of the building she and S6 Unit Manager found the exit door at the end of the Hall A propped open with a broom stick and S6 Unit Manager closed and secured the door. S7 RN reported she was unsure of time the Hall A exit door was closed but stated it was before Resident #1 and Resident #2 returned to the facility. S7 RN reported once Resident #1 and Resident #2 were returned to the facility she assessed Resident #1 for injuries and no injuries were found. During an interview on 09/19/2023 at 11:10 a.m. S6 Unit Manager reported prior to Resident #1 and Resident #2 being returned to the facility, she went down the Hall A through the fire doors where a plumber was working and found the Hall A exit door propped open. S6 Unit Manager reported she closed the Hall A exit door so no one else could get out. S6 Unit Manager reported she assessed Resident #2 after the elopement incident on 09/05/2023 and Resident #2 was assessed to have no injuries. During an interview on 09/19/2023 at 11:25 a.m. S8 Housekeeping reported when plumber arrived at the facility he took the plumber to the Hall A and showed the plumber what work needed to be done. S8 Housekeeping reported he unlocked the exit door on the Hall A for the plumber, and left him to do his work. S8 Housekeeping reported the plumber must have propped the door open once he left. S8 Housekeeping further reported once he heard residents had gotten out, he went to the Hall A exit door to shut it, but it was already closed. Resident #3 Review of Resident #3's medical record revealed a diagnosis of Dementia and major depressive disorder, MDS dated [DATE] revealed BIMS score of 9 indicating moderate cognitive impairment and no wandering during 7 day look back period. Review of Resident #3's Elopement Risk assessment dated [DATE] revealed Resident #3 was found to be at risk for elopement. Review of Resident #3's Comprehensive Care Plan dated 09/04/2023 revealed Resident #3 was care planned for risk of elopement with interventions including place resident's picture at exits to identify not to let resident out, note which exits resident favors for elopement and alert staff working near those areas. Visualize resident every shift for risk of elopement. Resident #4 Review of Resident #4's medical record revealed a diagnosis of Schizoaffective disorder, bipolar type and depression, MDS dated [DATE] revealed BIMS score of 5 indicating severe cognitive impairment, and no wandering during 7 day look back period. Review of Resident #4's Comprehensive Care Plan dated 07/11/2023 revealed Resident #4 was care planned for risk of elopement with interventions including Resident #4 likes to go to smoking door, alert staff working near that area. Picture placed at exits to identify not to let resident out. Visualize resident every shift for risk of elopement. The facility implemented the following actions to correct the deficient practice with completion on 09/12/2023: 1. Resident #1 and Resident #2 were immediately assessed for injuries upon their return on 09/05/2023 and NP and family notified 09/05/2023. 2. All exit doors checked to ensure they were closed and secured on 09/05/2023 immediately following elopement incident. 3. Safe Surveys were immediately conducted on all residents who were deemed to be at risk for elopement with surveys completed on 09/05/2023. 4. Sign was placed on Hall A exit doors stating Emergency Exit Use Only on 09/06/2023. Pictures of residents deemed to be at risk for elopement and signs stating Attention do not let any resident out without checking with nursing staff, doors to remain closed at all times were hung at each exit by end of day 09/07/2023. 5. On 09/05/2023 Administrator notified local plumbing company who was in the building working on Hall A of incident and instructed the company to ensure when they enter or exit the building to make sure doors are closed and secure behind them. Facility received a letter dated 09/12/2023 stating plumbing company had met with all employees and instructed the employees to follow facility policy on entering/exiting the building and ensuring doors are closed behind them at time of entrance or exit. Facility developed a Vendor Acknowledgement form for all vendors to sign in and acknowledge they have been instructed to ensure all doors remain closed and secure which was completed on 09/06/2023. 6. In-serviced staff on facility's Wandering and Elopement, making sure exit doors are secure and not propped open, maintenance staff to remain with vendors while vendors are at facility, and monitoring of residents at risk for elopement every two hours. In-service started on 09/05/2023 at 4:00 p.m., with maintenance staff, and was completed with all other staff by 09/09/2023. 7. All exits of the building have secure magnetic door locks including Hall A which were checked two times a day for one week starting 09/05/2023 and after one week doors checked once a day. Documentation of all door checks placed on door check log daily. The magnetic door locks require a code to be put in or a special key to be used to unlock the doors. This process is on-going and facility does not plan to discontinue this process. 8. All resident charts were reviewed for potential new diagnosis or behaviors putting them at risk for elopement and those deemed to be at risk had elopement risk assessments performed which were completed on 09/07/2023. Charts monitored at Quality Assurance meetings. 9. Care plans for all residents deemed to be at risk for elopement had their care plans updated to include increased supervision by end of day 09/07/2023. Orders to perform visual census checks every two hours received for residents deemed to be at risk for elopement and orders placed on each residents' EMAR (Electronic Medication Administration Record). 10. Quality Assurance and Performance Improvement meeting was conducted with department heads and medical director immediately following the incident and continues to evolve identifying areas of improvement including but not limited to possibly purchasing wander guard system. The QAPI committee is reviewing the quality assurance plan weekly for the first four weeks with start date of 09/06/2023, then will review plan monthly and as needed. 11. Resident #1 was transferred to a local inpatient behavioral hospital on [DATE] for further evaluation related elopement on 09/05/2023 and ongoing behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to have a system in place to ensure staff supervised resident who had orders for oxygen for 1 (#1) of 4 ( #1, #3, #4,#6) out of a total of 16 (#1, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents who smoke. The immediate jeopardy began for Resident #1 on 02/16/2023 at 1:40 p.m. when Resident #1 entered the secured smoking patio wearing nasal cannula and tubing which were connected to his O2 (oxygen) tank. Resident #1 proceeded to light a cigarette butt and caught his face on fire. Resident #6, who was smoking on patio, removed the O2 cannula and tubing from Resident #1's face in an attempt to put out the fire. Resident #1's O2 tank was found to have been releasing oxygen at 6L (liters) per minute. Resident #1 was transported to a local hospital for burns to his neck, face, tongue and right arm, where he was then transferred to a local Burn Unit and was intubated. S1 Administrator was notified on 02/23/2023 at 12:40 p.m. of the Immediate Jeopardy. The likelihood of harm or death continued for 3 (#3, #4, #6) other residents who were identified by the facility as smokers with orders for oxygen therapy. The facility presented the following Plan of Removal on 02/23/2023: 1. Resident #1 is no longer in facility as of 02/23/2023. 2. The code was changed on the smoking door on 02/23/2023 by Maintenance. 3. Scheduled staff was in-serviced on not allowing any resident with oxygen in the smoking area. All other staff will be in-serviced prior to work completed by 02/28/2023. 4. Staff assigned to Station 2 near smoking area, will observe resident's person to ensure there is no oxygen prior to entering the smoking area, started 02/23/2023. 5. Scheduled staff will be in-serviced on not to give the code to resident and if any resident is seen putting in the code Administration will be notified immediately to address. Started on 02/23/2023. All other staff will be in-serviced prior to work and completed by 02/28/2023. 6. S2 DON (Director of Nursing) and S5 SSD (Social Services Director) will identify all smokers that have oxygen therapy prescribed. Completed on 02/17/2023. Residents - #3, #4, and #6 identified as smokers that have oxygen therapy prescribed. 7. Review of resident smokers BIM (Brief Interview for Mental Status) scores and conduct new assessments to ensure no changes have occurred since last assessment started on 02/17/2023, by S5 SSD completed by 02/20/2023. This will be reviewed by S2 DON by 02/21/2023. 8. Review all smoking assessments and conduct new smoking assessments on all residents that smoke by S5 SSD were completed by 02/20/2023 and reviewed by S2 DON, S6 LPN (Licensed Practical Nurse) and S3 Unit Manager on 02/21/2023. a. Smoking assessments will then be completed quarterly, or with significant changes or as needed. 9. All residents that smoke reviewed smoking policy and have been given a copy and sign smoking policy acknowledgment form. Started 02/17/2023, by S3 Unit Manager and S7 LPN. Completed 02/21/2023. 10. Educated all residents that smoke and are on oxygen therapy with the risk of open flames and flammable oxygen and that oxygen is not allowed in designated smoking area. S3 Unit Manager and S7 LPN completed by 02/17/2023. 11. Educate residents on oxygen therapy that smoke on how to turn O2 tanks off with return demonstration and a sign will be placed into their room with the steps listed. S3 Unit Manager and S2 DON. Completed 02/17/2023. 12. Educate the general assembly of residents on the dangers and policy of oxygen in the designated smoking area. Completed 02/16/2023 in Resident Council meeting on 02/16/2023 with S2 DON and S5 SSD. Noted in the minutes of the meeting. Ombudsman also in attendance. 13. In-service staff on the risk and identifying oxygen in the designated smoking area and that no oxygen or tubing need to be in the designated smoking area. Started on scheduled staff 02/16/2023 and to be completed by all staff prior to work by 02/28/2023. 14. Random observation started 02/17/2023 of the designated smoking area and will be conducted by members of the QAPI (Quality Assurance and Performance Improvement) committee at a minimum of 3 times per day during daylight hours for 4 weeks, then at a minimum of 3 times per week for 4 weeks, then weekly thereafter and as needed. Observations will note if there are any safety issues, oxygen in the area and all will be noted and corrected. Administrator and/or DON will be notified immediately of any concerns. 15. Any negative findings from the Random Smoking are checks will be acted on by the Administrator immediately then report findings to the QAPI weekly for 30 days, then monthly thereafter. 16. Estimated completion 02/28/2023. The Immediate Jeopardy was removed on 02/23/2023 at 7:15 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Review of facility's Smoking policy revealed in part: 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building . Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. Resident #1 Review of Resident #1's ED notes dated 02/16/2023 revealed in part Resident #1's skin assessment noted burns to neck, face, mouth, tongue, right arm with soot and burn, and beard burned. Further review of ED notes revealed Resident #1 arrived to the ED via ambulance from the nursing home with facial burns. Resident #1 was smoking while wearing his oxygen resulting in an explosion with burns to his neck and face. Resident #1 was noted to have burns on his anterior neck, lips, tongue, nose, and oropharynx with soot noted in nares and on right arm. Resident #1 was intubated in the emergency department for airway protection. ED physician did speak with Dr. ____, consulted trauma physician, who recommends head and neck CT (Computerized Tomography). Review of MDM (Medical Decision Making) Narrative revealed in part Resident #1 has some blistering and changes which appear to be burns of the anterior tongue. Resident #1 complains of pain in his tongue and a burning sensation going from his posterior oropharynx down to his mid chest. He has soot in his nares first-degree burns around his anterior nose lower face and anterior neck. Review of Resident #1's CT report revealed in part findings of burn and smoke inhalation and trauma. Resident #1 was transferred to a local Burn Unit and was intubated. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), major depressive disorder, anxiety disorder, gangrene and necrosis of the lung, and nicotine dependence. Resident #1 was discharged from the facility on 02/16/2023 with a return anticipated. Review of Resident #1's MDS (Minimum Data Set) dated 01/11/2023 revealed Resident #1 had a BIMS summary score of 11 out of 15 indicating Resident #1's cognition was moderately impaired. Further review of Resident #1's MDS revealed Resident #1 was coded for oxygen therapy and had experienced SOB (shortness of breath) with exertion, when sitting at rest and when lying flat during a 5 day MDS look back period. Review of Resident #1's physician's orders revealed an order dated 02/06/2023 which read O2 at 2 liters via nasal cannula as needed for SOB or Saturation (Sat.) less than 90% and O2 Sat. every shift. Review of Resident #1's current care plan revealed Resident #1 was noncompliant with oxygen by turning up oxygen above prescribed liters. A care plan revision dated 02/06/2023 revealed Resident #1 had interventions which prohibited Resident #1 from entering the smoking patio wearing oxygen or carrying oxygen tank. Review of Resident #1's Interdisciplinary notes revealed a nurse's note written by S3 Unit Manager dated 02/06/2023 at 3:43 p.m. which read in part: Met resident in hallway in wheelchair. Visibly short of breath. Insisted he go outside to smoke.sat. 83% RA (room air). Asked if he really wanted to go out and smoke with sat. of 83%. Reported Yes. Yes I do. I have been in the hospital I need to go outside. I need that oxygen in there too. Advised against decision to smoke. Continued to insist and rolled to smoking porch. Further review of Resident #1's Interdisciplinary notes revealed a nurse's note written by S9 RN (Registered Nurse) dated 02/16/2023 at 2:07 p.m. which read in part: Resident outside smoking with oxygen tank. 1:40 p.m. Alerted by S8 LPN that resident caught himself on fire. 911 called. Resident stated my lighter blew up. Resident had blackened areas to nose, face, beard, neck and bilateral hands. Areas cooled with towel . 1:50 pm Resident #1 transported to _____ ER (Emergency Room). No next of kin. Incident witnessed by Resident #6 who pulled tubing from Resident #1's tank. Noted end of tubing black in color. During an interview on 02/22/2023 at 10:20 a.m. S3 Unit Manager reported oxygen was not permitted on the smoking patio. S3 Unit Manager further reported she had often redirected Resident #1 when he would wheel towards patio with O2 tank and would remind Resident #1 oxygen was not allowed on the patio. During an interview on 02/22/2023 at 11:45 a.m. Resident #6, reported he had never witnessed Resident #1 on the smoking patio with his oxygen in use prior to the accident on 02/16/2023. Resident #6 reported he was present on the smoking patio on 02/16/2023 when Resident #1 wheeled out onto the smoking patio. Resident #6 further reported Resident #1 lit a cigarette butt and was consumed in flames. Resident #6 reported Resident #1 tried to pat the fire out but the fire kept coming back. Resident #6 reported he told Resident #1 to take off his oxygen but Resident #1 responded with I can't, like he was panicked. Resident #6 reported he then snatched the tubing off of Resident #1's face and beat on the patio door for help. Resident #6 confirmed Resident #1 was wearing his nasal cannula but was very hard to see because Resident #1 had a thick beard and the tubing was clear. Resident #6 reported he could see Resident #1's O2 tank tucked into his wheelchair beside his right leg. Resident #6 further reported he himself knew the code to enter the smoking patio but Resident #1 did not know the code. During an interview on 02/22/2023 at 12:00 p.m. Resident #3, reported she had never witnessed Resident #1 on the smoking patio with oxygen. Resident #3 further reported she knew the code to get onto the patio. Resident #3 reported Resident #1 did not know the code to get out to the smoking patio. Resident #3 further reported Resident #1 would not have been physically capable of reaching the key pad since his recent hospitalization, if he did know the code. During an interview on 02/22/2023 at 1:20 p.m. S10 Relief Unit Clerk, reported when she arrived to relieve staff for lunch Resident #1 was already outside on the smoking patio. S10 Relief Unit Clerk further reported she saw the fire and went and got S8 LPN to attend to resident. S10 Relief Unit Clerk acknowledged Resident #1 would have been dependent upon staff letting him out the door to smoke. During an interview on 02/22/2023 at 1:30 p.m. S9 RN reported she was Resident #1's nurse on 02/16/2023 and was notified of the incident after the fire had been distinguished. S9 RN further reported Resident #1 was known to wheel himself around facility with oxygen on and acknowledged someone should have stopped him from going out to smoke. During an interview on 02/22/2023 at 1:55 p.m. S11 AD (Activity Director) reported she had not let Resident #1 out to the smoking patio on 02/16/2023 and was not aware of how Resident #1 gained access to the patio while wearing oxygen. S11 AD further reported some of the residents who smoke knew the code but was unsure how they were given the code. S11 AD further reported had not recalled ever seeing Resident #1 using the code to enter the smoking patio. During an interview on 02/23/2023 at 8:05 a.m. S12 Unit Clerk reported a lot of the smokers knew the code and would go out to smoke as they wanted. S12 Unit Clerk further reported she was aware Resident #1 required O2 at times and would have been able to see the nasal cannula and tubing on Resident #1, despite his facial hair. S12 Unit Clerk further reported Resident #1 required more assistance after his hospitalization and would often need help with the door to come back in from smoking. During an interview on 02/23/2023 at 08:40 a.m. S13 PT (Physical Therapist) reported Resident #1 had been very active and walked around the facility prior to his recent hospitalization. S13 PT further reported Resident #1 was dependent upon a wheelchair to get around after returning to facility. During an interview on 02/23/2023 at 8:50 a.m. Resident #7 reported he witnessed Resident #1 on the patio on 2/16/2023 wearing his nasal cannula. Resident #7 further reported he and Resident #1 discussed the flammability and risks of having oxygen on the smoking patio prior to Resident #1 smoking. Resident #7 reported Resident #1 turned off his oxygen and retrieved a cigarette butt from the ash tray caddy. Resident #7 further reported Resident #1 proceeded to light the cigarette butt and the fire ignited. Resident #7 reported that Resident #1 must have turned his oxygen up and not off. During an interview on 02/23/2023 at 9:50 a.m. S5 SSD reported Resident #1 had always been independent and knew the code to the smoking patio. S5 SSD further reported Resident #1 would go out and smoke with his girlfriend and would even go out at night after hours utilizing the key pad, in the past. S5 SSD further reported she conducted the Safe Smoking Assessment on Resident #1 upon return from hospital and Resident #1 was designated as a safe smoker. S5 SSD further reported Resident #1 was very weak from his recent hospitalization and was not going out to smoke as much. S5 SSD further reported Resident #1 had received a wheelchair and began to start smoking again. During an interview on 02/22/23 at 2:20 p.m. S2 DON confirmed some of the residents who smoke know the code to unlock the door to the smoking area. S2 DON acknowledged even if residents were aware of the code to get to the smoking area, the facility was still responsible for the residents' safety. S2 DON reported Station 2's staff should confirm residents have removed their oxygen prior to going into the smoking area. S2 DON acknowledged staff were aware Resident #1 had orders for oxygen. S2 DON acknowledged facility had no policy regarding code access to smoking patio. During an interview on 02/23/2023 at 12:45 p.m. S2 DON reported she interviewed Resident #1 via telephone today and Resident #1 reported he rolled to the door on 02/16/2023 and someone let him out. During an interview on 02/23/2023 at 6:00 p.m. S1 Administrator and S14 Regional [NAME] President acknowledged the facility failed to supervise Resident #1 from entering the smoking patio with Oxygen in place. S1 Administrator and S14 Regional [NAME] President confirmed Resident #1 suffered harm when Resident #1 attempted to light a cigarette while receiving oxygen via nasal cannula.

Based on interviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to ensure staff supervised resident who had orders for oxygen for 1 (#1) of 4 ( #1, #3, #4,#6) out of a total of 16 (#1, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents who smoke. The immediate jeopardy began for Resident #1 on 02/16/2023 at 1:40 p.m. when Resident #1 entered the secured smoking patio wearing nasal cannula and tubing which were connected to his O2 (oxygen) tank. Resident #1 proceeded to light a cigarette butt and caught his face on fire. Resident #6, who was smoking on patio, removed the O2 cannula and tubing from Resident #1's face in an attempt to put out the fire. Resident #1's O2 tank was found to have been releasing oxygen at 6L (liters) per minute. Resident #1 was transported to a local hospital for burns to his neck, face, tongue and right arm, where he was then transferred to a local Burn Unit and was intubated. S1 Administrator was notified on 02/23/2023 at 12:40 p.m. of the Immediate Jeopardy. The likelihood of harm or death continued for 3 (#3, #4, #6) other residents who were identified by the facility as smokers with orders for oxygen therapy. The facility presented the following Plan of Removal: 1. S14 RVP (Regional [NAME] President) will in-service S1 Administrator to ensure an adequate system is in place to ensure residents are supervised to prevent smoking with oxygen in the smoking area. Started and completed on 02/23/2023. 2. S14 RVP or a QI (Quality Improvement) nurse will randomly review system to ensure S1 Administrator and S2 DON (Director of Nursing) maintain an adequate system in place to ensure residents are supervised to prevent smoking with oxygen in the smoking area. Started 02/23/2023 and to be completed by 02/28/2023. 3. The Administrative staff will conduct and complete random smoking area checks on 02/23/2023 to ensure that any further potential injuries will not occur. a. Random smoking area checks will be conducted by Administrative designees daily for 30 days, then weekly thereafter. b. Any negative finding will be reported to the Administrator and acted on immediately. 4. S1 Administrator reviewed the completed random smoking area checks on 02/23/2023 to determine if any potential injuries had occurred. a. Random smoking area checks will be reviewed by S1 Administrator daily for 30 days then weekly thereafter. Any negative finding will be acted upon immediately. 5. Any negative findings from the random smoking area checks will be acted on by S1 Administrator immediately then report findings to the QAPI (Quality Assurance and Performance Improvement) committee weekly for 30 days, then monthly thereafter. 6. Estimated completion date 02/28/2023. The Immediate Jeopardy was removed on 02/23/2023 at 7:15 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings, Cross Reference F689: During an interview on 02/22/23 at 2:20 p.m. S2 DON confirmed some of the residents who smoke know the code to unlock the door to the smoking area. S2 DON acknowledged even if residents were aware of the code to get to the smoking area, the facility was still responsible for the residents' safety while smoking. S2 DON reported Station 2's staff should confirm residents have removed their oxygen prior to going into the smoking area. S2 DON acknowledged staff were aware Resident #1 had orders for oxygen. S2 DON acknowledged facility had no policy regarding code access to smoking patio. During an interview on 02/23/2023 at 12:45 p.m. S2 DON reported she interviewed Resident #1 via telephone today and Resident #1 reported he rolled to the door on 02/16/2023 and someone let him out. During an interview on 02/23/23 at 6:00 p.m. S1 Administrator and S14 Regional [NAME] President acknowledged the facility failed to supervise Resident #1 from entering the smoking patio with oxygen in place. S1 Administrator and S14 Regional [NAME] President confirmed Resident #1 suffered harm when Resident #1 attempted to light a cigarette while receiving oxygen via nasal cannula.

Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by a staff member for 1 (Resident #1) of 8 (Residents #1, #2, #3, #4, #5, #6, #7, #8) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1, who is cognitively impaired, on 10/18/2022 when S3 CNA (Certified Nursing Assistant) physically and verbally abused Resident #1 in Resident #1's room by aggressively pulling Resident #1's head up when sitting on the floor and yelled directly into Resident #1's ear, Stop Yelling. Resident #1 was noted to be agitated and fearful and told S3 CNA Don't kill me, don't kill me. On 10/19/2022 S1 Administrator and S2 DON (Director of Nursing) were made aware of the abuse by S3 CNA by viewing the video surveillance provided by Resident #1's Responsible Party (RP). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility failed to implement protective measures to protect the other vulnerable residents in the facility. S1 Administrator and S2 DON were notified of the immediate jeopardy on 12/14/2022 at 5:10 p.m. The immediate jeopardy was removed on 12/15/2022 at 5:47 p.m. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal (POR) have been initiated and/or implemented prior to exit. The facility's POR included the following: 1. Resident #1 was assessed with no injuries noted from abuse on 10/19/2022 by S4 RN (registered nurse). 2. Staff member in question was terminated on 10/20/2022. 3. Safe survey checks were conducted and completed on 12/15/2022 on all residents by Administration staff to assess, identify, and prevent abuse. a. Safe Survey Checks will be conducted by Administrative staff or designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 4. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 12/15/2022. a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 5. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment of residents prior to shift start, by Administrative staff or designee by 12/19/2022. 6. We are going to put in place an Abuse Prevention Program initiated by Administration. The Administrator will provide opportunities for staff to express challenges related to their job and work environment by open door practice starting 12/14/2022. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 12/14/2022 on abuse prevention program. b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start, by Administrative staff or designee by 12/19/2022. 7. Administrator/Designee will in-service all scheduled staff related to Burn Out/Signs and Symptoms, and report to the administrator starting 12/15/2022. a. All remaining employees will be in-serviced on burn out prior to shift start, by Administrative staff or designee by 12/19/2022. b. Administrator/Designee will do random observation of staff interactions with residents to monitor for signs and symptoms of burn out, three times a week for 30 days, then monthly thereafter. Starting 12/19/2022. c. RVP (Regional [NAME] President) or QI (Quality Improvement) nurse will ensure Administrator/Designee is conducting random observation of staff interactions with residents weekly times 30 days. 8. Any negative findings from the Safe Survey Checks will be acted on by the Administrator immediately, then report findings to the Q.A.P.I. (Quality Assurance/Performance Improvement) weekly for 30 days, then monthly thereafter. 9. Estimated completion date 12/19/2022. Findings: Review of the facility Abuse and Neglect - Clinical Protocol (Revised October 15, 2022) revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation - Staff to Resident Abuse of any Types: Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally. The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation from staff is abuse, regardless of whether harm was intended. Definitions: Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. Physical Abuse - this includes but is not limited to hitting, slapping, pinching, and kicking. Record review of Resident #1's medical record revealed the following diagnoses, in part: Alzheimer's disease, Schizoaffective disorder, anxiety disorder, dementia, and depression. Record review of Resident #1's care plans revealed the following, in part: Impaired thought process related to Alzheimer's, dementia, Schizoaffective disorder, and aphasia. Interventions included, provide consistent caregiver on all shifts, call light in reach, monitor and document resident behavior and status as needed and report cognitive status to MD (Medical Doctor). Electronic monitoring/camera in room per resident and family request, managed by family related to resident dignity will be maintained and protected the next review. Interventions included placement of camera to ensure privacy during care for resident and roommate and keep sign posted on door. Record review of Resident # 1's MDS (minimum data set) dated 10/4/22 revealed the resident's BIMS (brief interview of mental status) score was 99, which indicated unable to complete the interview. Observation with an interview on 12/12/2022 at 11:25 a.m., revealed Resident #1 in reclining chair that was reclined. Appearance was clean and kept. No foul odors noted. Resident #1 was able to say he was doing okay when asked. Resident #1 would partially talk normal then would do a loud moaning sound that was not understandable. Observation on 12/13/2022 at 6:40 a.m., revealed Resident #1 resting in bed with eyes closed. No foul odors noted. Resident #1 had clean and kept appearance. Bed sheet and blankets were arranged in an orderly manner. Room appeared clean. During a telephone interview on 12/12/2022 at 3:15 p.m., Resident #1's RP indicated after she saw the videos of 10/18/2022 of S3 CNA handling Resident #1 roughly she showed the videos to S1 Administrator and S2 DON. Resident #1's RP confirmed the video showed S3 CNA was attempting to assist Resident #1 out of the recliner. S3 CNA got Resident #1 up and Resident #1 went to the floor. S3 CNA attempted to get Resident #1 off the floor, by grabbing the back of Resident #1's head and pulling his head up in a rough manner. After S3 CNA got Resident #1 back in bed, S3 CNA leaned over and put her mouth right by the resident's ear, close enough to kiss his ear, and yelled at the top of her lungs, Stop yelling! Resident #1's RP stated Resident #1 was a preacher and he served to help others and he did not deserve to be treated this way. Review of five video clips, with audio, provided by Resident #1's RP dated 10/18/2022, time-stamped from 12:51p.m. through 1:04 p.m., revealed in summary Resident #1 was in a recliner that was positioned towards the right lower side of the bed. S3 CNA grabbed Resident #1's hands attempting to assist Resident #1 out of the recliner. Resident #1 was unable to stand and S3 CNA guided him to the floor where he landed softly on his buttocks. S3 CNA then moved the Resident #1 next to the side of the bed while the resident remained on the floor. Resident #1 was next to the bed and S3 CNA grabbed the back of Resident #1's head/neck and aggressively pulled Resident #'s head upwards towards her. S3 CNA left the room while Resident #1 was sitting on floor with upper torso leaning on the side of the bed. S3 CNA reentered the room and appeared to be texting on her phone. S3 CNA then exited the room again. The next video showed Resident #1 was in bed with S3 CNA was next to bed. Another staff member was present for a short time before exiting the room. S3 CNA was seen changing Resident #1's adult diaper. S3 CNA was verbally yelling in the room almost constantly, I hate this place, I am getting out of here, you need a man to take care of you, I am over this . S3 CNA put bed sheet over Resident #1 after completing adult diaper change. Resident #1 yelled out and S3 CNA leaned over and placed her mouth right next to Resident #1's right ear and screamed very loudly, Stop yelling! S3 CNA then lowered the bed Resident #1 was lying in to low position. During a telephone interview on 12/14/2022 at 12:34 p.m., S3 CNA indicated the day of the incident with Resident #1, she got him in the recliner and when checking on the resident she noticed his diaper was wet. S3 CNA confirmed when she attempted to get Resident #1 up he wouldn't stand up and help and resident #1wound up sitting on floor. S3 CNA left the room to try to find somebody to help her. S3 CNA brought another CNA to help her and they got Resident #1 in bed and she changed Resident #1's diaper. S3 CNA admitted that when she was trying to get Resident #1 into bed from the recliner she did not do it correctly. S3 CNA indicated she did not jerked the resident by his head and she quietly told Resident #1 to stop yelling. S3 CNA indicated she was called to S1 Administrator's office two days later and she was terminated. During an interview on 12/12/2022 at 2:15 p.m., S5 LPN (licensed practical nurse) indicated she knew Resident #1 RP had shown S1 Administrator and S2 DON the videos of S3 CNA handling Resident #1 roughly. S5 LPN indicated she did not see the videos but she heard from other staff members S3 CNA grabbed Resident #1's neck roughly when attempting to get the resident off of the floor. S5 LPN further indicated S3 CNA was terminated after the incident. S5 LPN then indicated that another resident (Resident #3) informed her that S3 CNA told Resident #3, I'm sick of all y'all lazy a** people not doing anything for yourself. S5 LPN indicated this was told to her after S3 CNA was terminated and S5 LPN reported it to S2 DON. During an interview on 12/12/2022 at 2:30 p.m., Resident #3 indicated that S3 CNA would always talk to her mean, saying things like she hated this place and hating her job. Resident #3 confirmed S3 CNA told her, Y'all know what y'all need?, Y'all need to get off your lazy a**es and start doing for yourself. Review of Resident #3's medical record revealed a 9/30/2022 BIMS (Brief Interview of Mental Status) score of 10 out of 15 indicating mildly impaired. During an interview on 12/13/22022 at 1:15 p.m., Resident #6 did not know S3 CNA was terminated and at first she was hesitant to say anything. Resident #6 was informed S3 CNA had been terminated, Resident #6 indicated S3 CNA would talk very rough and mean to her. Resident #6's son was at bedside during the interview and he asked his mother, Was that the one you called me about being rough? and then Resident #6 replied to her son, yes. Review of Resident #6's medical record revealed a BIMS score on 11/10/2022 of 4 out of 15 indicating a cognitive status of moderately impaired. During an interview on 12/13/2022 at 1:30 p.m., S6 CNA indicated S3 CNA talked mean to her. S6 CNA worked the opposite side of the hall, S3 CNA told her to stay on her side and don't come down S3 CNA'S hallway. S6 CNA also indicated she would go to another hall to get ice for her residents because she didn't want to go to S3 CNA's hall to get the ice. During an interview on 12/13/2022 at 1:45 p.m., Resident #5 indicated S3 CNA had a real bad attitude and kept everything in an uproar. Resident #5 acknowledged once S3 CNA was gone, things got a lot better. Review of Resident #5's medical record revealed a BIMS score on 10/28/2022 of 12 out of 15 indicating a cognitive status of mildly impaired. During an interview on 12/13/2022 at 7:05 a.m., S2 DON indicated Resident #1's RP showed her the video of S3 CNA interacting with Resident #1. S2 DON indicated the videos showed Resident #1 on the floor by his bed, S3 CNA took her hands and placed them behind the resident's neck and then roughly yanked the resident to an upright position. Another video showed S3 CNA putting her mouth directly next to Resident #1's ear and S5 CNA screamed, Shut up! into his ear. S1 Administrator and S2 DON called S3 CNA to the office, S3 CNA told them she just, Lost it. and S3CNA was terminated. S2 DON acknowledged the facility did not assess all residents for any abuse or mistreatment after an abuse allegation was revealed. During an interview on 12/13/2022 at 10:35 a.m., S1 Administrator indicated he had watched the videos shown to him by Resident #1's RP and it showed S3 CNA grab the back of Resident #1's head and forcefully pulled him in upright position. S1 Administrator confirmed the video also showed S3 CNA screaming into Resident #1's ear, Stop hollering! S1 Administrator called S3 CNA to his office and S3 CNA indicated that she Lost it. S3 CNA was terminated on 10/20/2022. S1 Administrator was asked by the surveyor if law enforcement was notified of the staff to resident abuse to which he replied No. During an interview on 12/15/22 at 5:00 p.m., S1 Administrator verified they did not put a system in place to ensure the deficient practice will not happen again. S1 Administrator further verified they did not conduct any ongoing monitoring of residents for evidence of abuse.

Based on observations and interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure: 1. Resident #1 was not physically and verbally abused and psychosocially harmed by staff 2. A system was put in place to ensure physical and verbal abuse and psychosocial harm will not happen again and put in place ongoing monitoring of residents for evidence of abuse 3. All residents were assessed and/or interviewed regarding concerns of mental, physical, verbal and/or sexual abuse 4. Facility staff was assessed for burnout sign and symptoms. This deficient practice resulted in an immediate jeopardy for Resident #1, who is cognitively impaired, on 10/18/2022 when S3 CNA (Certified Nursing Assistant) physically and verbally abused Resident #1 in Resident #1's room by aggressively pulling Resident #1's head up when sitting on the floor and yelled directly into Resident #1's ear, Stop Yelling. Resident #1 was noted to be agitated and fearful and told S3 CNA Don't kill me, don't kill me. On 10/19/2022 S1 Administrator and S2 DON (Director of Nursing) were made aware of the abuse by S3 CNA by viewing the video surveillance provided by Resident #1's Responsible Party (RP). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility failed to implement protective measures to protect the other vulnerable residents in the facility. S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 12/14/2022 at 5:10 p.m. The Immediate Jeopardy was removed on 12/15/2022 at 5:47 p.m. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal (POR) have been initiated and/or implemented prior to exit. The facility's POR included: 1. Administrator was in-serviced by Regional [NAME] President (RVP) on Abuse Investigation and Reporting on 12/14/2022 at 7:30 p.m. 2. Administrator was in-serviced by RVP on Burn Out/Signs and Symptoms on 12/15/2022. a. RVP or Quality Improvement Nurse (QI) Nurse will ensure Administrator/Designee is conducting random observation of staff interactions with residents weekly times 30 days. 3. The Administrative Staff will conduct and complete safe survey checks on 12/15/2022 to ensure that any further potential abuse, neglect or mistreatment is prevented. a. Safe survey checks will be conducted by administrative staff or designees on random residents weekly for 30 days, then monthly thereafter. b. Any negative finding will be reported to the Administrator and acted on immediately. 4. The Administrator reviewed the completed safe survey checks on 12/15/2022 to determine if any abuse, neglect or mistreatment has occurred. a. Safe survey checks will be reviewed by Administrator weekly for 30 days, then monthly thereafter. Any negative findings will be acted upon immediately. 5. After abuse investigation is completed by the facility it will be reviewed by Regional [NAME] President or Quality Improvement Nurse prior to closing SIMS. 6. Any negative findings from the safe survey checks will be acted on by the Administrator immediately then report findings to the Q.A.P.I. (Quality Assurance/Performance Improvement) weekly for 30 days, then monthly thereafter. 7. Estimated completion date 12/19/2022. Findings, Cross Reference F600: Review of the facility Abuse and Neglect - Clinical Protocol (Revised October 15, 2022) revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation - Staff to Resident Abuse of any Types: Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally. The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation from staff is abuse, regardless of whether harm was intended. Definitions: Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. Physical Abuse - this includes but is not limited to hitting, slapping, pinching, and kicking. During an interview on 12/15/2022 at 4:35 p.m., S1 Administrator and S2 DON acknowledged the facility did not assess all residents for any abuse or mistreatment after an abuse allegation was revealed to S1 Administrator and S2 DON and the facility did not assess staff for burnout signs and symptoms. During an interview on 12/15/22 at 5:00 p.m., S1 Administrator verified they did not put a system in place to ensure the deficient practice will not happen again. S1 Administrator further verified they did not conduct any ongoing monitoring of residents for evidence of abuse. S1 Administrator confirmed they did not conduct any ongoing monitoring of staff to detect signs and symptoms of burnout.